2.0 Analysis 2.1 Bridge Team Communication The BURRARD BEAVER departed from the terminal in poor visibility with vessels known to be operating in her proximity. Because of the fog, the necessity of maintaining a listening watch limited communication between the master and the mate. There was also no discussion between them on how the movement of other traffic might affect the ferry on this transit. 2.2 Safe Passing Arrangement As the BURRARD BEAVER and the ORCA SPIRIT were operating in the vicinity of adjacent terminals in some 30 m visibility, good seamanship practice dictates that the vessels should have established communication and made their intentions known to each other in the interest of safety. However, this was not done. 2.3 Mate's Actions and Response to Master's Orders The mate concurs that the master had twice ordered a course alteration to starboard and that he did not carry out the master's orders. Although the mate intended to give a wider berth to the ORCA SPIRIT which was on his port side, he reportedly did not alter course to starboard since he believed that would cause the vessel's stern to swing closer to the ORCA SPIRIT. Although the mate maintained that he could not effectively monitor the radar screen because the master had turned it away from him, the master denies that such was the case. Despite this and the mate's concern for the course alteration to starboard, he neither indicated his concerns to the master nor did he take a more appropriate, safer measure such as stopping or reversing the engines. 2.4 Mate's Apparent Unfamiliarity with the Vessel's Manoeuvring Characteristics The vessel's manoeuvring characteristics were such that a change in direction of a track could be effected without altering the heading. As the mate feared that a starboard course alteration would result in the stern of the BURRARD BEAVER coming closer to the ORCA SPIRIT, it would suggest the mate's lack of appreciation of the vessel's manoeuvring characteristics even if the mate had been operating the ferry for the past eight years. This is further reflected in the mate being unable to provide exact information on the ferry's stopping distance. 3.0 Conclusions 3.1 Findings Before departure from the berth, both the master and the mate of the BURRARD BEAVER were aware of the traffic in the ferry's vicinity. There was no discussion between the master and the mate respecting the traffic movement in the vicinity and how it might affect the ferry on this transit. The BURRARD BEAVER departed the berth in poor visibility without first establishing very high frequency radiotelephone contact with other vessels operating in the vicinity to establish/confirm their intentions. None of the vessels operating in the vicinity responded to the Scurit call from the BURRARD BEAVER. The presence of other vessels in the vicinity did not inhibit the manoeuvres of the BURRARD BEAVER nor did it interfere with the ferry's normal courses. The mate, who was at the controls and had the conduct of the vessel, did not carry out the master's orders to alter course to starboard. The mate could not see the radar screen but continued with a course alteration to port instead of stopping or reversing the vessel's engines to give more time to evaluate the situation. The mate did not fully appreciate the manoeuvring characteristics of the BURRARD BEAVER. The master was unable to reach the control for two of the four main engines but he did use the other control in astern mode. There is no regulatory requirement or a company/union policy for the crew to be subjected to annual or periodic medical examination. The public address system was not used in good time to inform the passengers of the accident or reassure them of their safety. 3.2 Causes Upon departing Vancouver Terminal in poor visibility, the BURRARD BEAVER struck the Canada Place dock due to a manoeuvring error. Contributing factors to the striking were a lack of appreciation of the special manoeuvring capabilities of the ferry and the need to maintain a listening watch which reduced verbal communication between the bridge team. 4.0 Safety Action 4.1 Action Taken Following the accident, the operator of the BURRARD BEAVER (BC Transit) took the following actions: An order of precedence was established between BC Transit and Royal Sea Link ferries at the Vancouver Terminal. However, the Royal Sea Link ferry service to Nanaimo using the ORCA SPIRIT was discontinued in June 1993 and the Victoria run using the ROYAL VANCOUVER and ROYAL VICTORIA was discontinued in September 1993. Masters and mates employed by BC Transit have been offered a refresher course in the use of radar at the Pacific Marine Training Institute. An out-of-service ferry has been used for hands-on training in manoeuvrability for ferry officers, and the crews have been drilled in passenger evacuation. The automatic whistle sounding device on the BURRARD BEAVER was updated after the striking. Management has implemented a policy of changing and rotating the bridge teams; instead of the master and mate operating as a relatively fixed team, they are rotated in an endeavour to alleviate possible conflicts and complacency, and to increase awareness and efficiency.